Market Failure

Excellent story in the NYT yesterday exploring the lack of dental care among the working poor. Reed Abelson, the reporter, starts and ends with a little-publicized fact about reservists heading out to Iraq:

Among the nation's reservists, a common reason for not being sent to Iraq has been poor teeth. The military offers dental insurance to reservists and members of the National Guard, but for those who opt for it, the benefit of $1,200 a year does not cover many procedures and still requires reservists to pay as much as half the cost of the care.

And then he extends the problem to the wider community of working poor:

In a nation where a person's smile is considered a sign of general well-being and an important factor in landing a job, dental care is becoming ever more unequal, policy specialists say. In 2000, the surgeon general issued a report describing the silent epidemic of dental and oral diseases affecting mainly the poor, but some specialists, including those working at community clinics, say the problem is becoming worse.

Each year, Americans spend about $70 billion on dental services, ranging from basic checkups to sophisticated dental implants and new cosmetic whitening treatments. But for all that spending, what has evolved is a double standard of care, with the haves getting movie star smiles and the have-nots more likely to be living with mouths full of bad or missing teeth.

Only about half of the country has any form of dental insurance, by some estimates. Most employers do not offer the benefit, and dental coverage is often one of the first things companies cut to reduce costs. In 2003, 39 percent of employers offered dental benefits, according to a Kaiser Family Foundation study, compared with 66 percent that offered health insurance.

And as employers continue to grapple with double-digit increases in their health care spending, a recent survey by the Council of Insurance Agents and Brokers, a trade association, found that many are likely to drop dental coverage altogether or ask employees to foot more of the bill. Among the 45 million people without any health insurance, dental services - costs have risen by about 50 percent in the last decade, above inflation - is a low priority.

As the story later points out, dental health is no small deal. Poor oral health is linked to heart disease and premature labor. Emergency treatment for ignored problems is high and often inadequate. When patients do get to a dentist, they are forced to have their teeth pulled instead of opting for better, more expensive solution.

But the question of basic healthcare denied to the working poor is not a new story. Mick at Omnium has posted about it. Jeanne posted a personal story about vision care back in February in response to a NYT magazine article about what the working poor have to do without. From that article:

The people who received promotions tended to have something that Caroline did not. They had teeth. Caroline's teeth had succumbed to poverty, to the years when she could not afford a dentist. Most of them decayed and abscessed, and when she lived on welfare in Florida, she had them all pulled in a grueling two-hour session that left her looking bruised and beaten. Under the state's Medicaid rules as she understood them, a set of dentures would have been covered only if she had been without any teeth at all; while some of them could have been saved, she couldn't afford to do less than everything. In the end, the dentures paid for by Medicaid didn't fit and made her gag, so she couldn't wear them. An adjustment would have cost about $250, money she didn't have.

Probably no employer would ever admit to passing her over because she was missing that radiant, tooth-filled smile that Americans have been taught to prize as highly as their right to vote. Caroline had learned to smile with her whole face, a sweet look that didn't show her gums, yet it came across as wistful, something less than the thousand-watt beam of friendly delight that the culture requires. Where showing teeth was an unwritten part of the job description, she did not excel. She was turned down for a teller's position with the Claremont Savings Bank, which then hired her for back-room filing and eventually fired her from that. Wal-Mart considered her for customer-service manager and then promoted someone else, someone with teeth.

Caroline's is the face of the working poor, marked by a poverty-generated handicap more obvious than most deficiencies but no different, really, from the less visible deficits that reflect and reinforce destitution. If she were not poor, she would not have lost her teeth, and if she had not lost her teeth, perhaps she would not have remained poor. Poverty is a peculiar, insidious thing, not just one problem but a constellation of problems: not just inadequate wages but also inadequate education, not just dead-end jobs but also limited abilities, not just insufficient savings but also unwise spending, not just the lack of health insurance but also the lack of healthy households. The villains are not just exploitative employers but also incapable employees, not just overworked teachers but also defeated and unruly pupils, not just bureaucrats who cheat the poor but also the poor who cheat themselves.

The theme starts to expand at the end of the citation. Caroline's dental problems are just a springboard for a very long article. But poverty is the body politic's dental health. It's easy to see when it gets bad enough. It's easy to ignore because it appears isolated. But it's pernicious and it will eventually be felt everywhere throughout the system. By then the treatment has lost sight of the root cause and we're stuck treating symptoms and not well at that.